Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are appealing this denial. The Plan denied your 
request. The Plan says the enrollee does not meet Medicare criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that an 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 based on the documentation provided, the health plans denial should be upheld.  
The enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not 
shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollees care needs can be met 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an IRF admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on July 6, 2022, billed with 
codes 0031U, 0032U, 0033U, 81227, 81230, 81231, 81232, 81291, 81306, 81335, 81355, 81407 and 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was necessary and is 
supported in the medical record. The Plan denied your request. The Plan says panel testing should be billed 
using one CPT code on the claim. 
 
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 
July 6, 2022, billed with codes 0031U, 0032U, 0033U, 81227, 81230, 81231, 81232, 81291, 81306, 81335, 
81355, 81407 and 81479.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for principal care management services provided on July 20, 
2022, by an OON provider. 
 
You asked the Plan to pay for principal care management services. You say that the enrollee resides in a 
nursing home setting and could not choose an in-network provider. The Plan denied your request. The Plan 
says the enrollee must receive care from a network 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 principal care management services provided on 
July 20, 2022, by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve below knee alignable system, flex-walk system, and 
multiaxial rotation unit. 
 You asked the Plan to pre-approve below knee alignable system, flex-walk system, and multiaxial rotation unit. 
You say that you disagree with the Plan's denial. The Plan denied your request. The Plan says the requested 
items are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that prosthesis additions are only covered for certain 
indications. 
 
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 below knee alignable system, flex-walk 
system, and multiaxial rotation unit. Our reviewer says that the documentation does not support that the 
requested items are medically reasonable or necessary. Our physician reviewer found the enrollee had a 
previous right-sided below the knee amputation. The documentation indicates the enrollee uses a walker and a 
wheelchair for longer distances. A level 3 ambulator has the ability or potential for ambulation with variable 
cadence. Typical of the community ambulator who has the ability to traverse most environmental barriers and 
may have vocational, therapeutic or exercise activity that demands prosthetic utilization beyond simple 
locomotion. In this case, the enrollee has been authorized to have replacement parts for an ill-fitting prosthesis. 
The requested upgraded components including an alignable system, flex-walk system or equal and a multiaxial 
rotation unit are not medically 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 below knee alignable system, flex-walk system, and multiaxial rotation unit 
have not been met. Therefore, we decided that the Plan does not have to pre-approve below knee alignable 
system, flex-walk system, and multiaxial rotation unit.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a computed tomography scan provided on March 18, 2022. 
 
You asked the Plan to pay for a computed tomography scan. You say that this was medically necessary. The 
Plan denied your request. The Plan says you should not have any financial responsibility for this service. 
 
The Plan must follow Medicare rules. Medicare rules say that when services or supplies are rendered by a non-
contracting, original Medicare, participating provider, there is no balance billing paid by either the Plan or the 
enrollee.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a computed tomography scan have not been met. Specifically, the record indicates that the Plan has 
paid the Medicare allowed amount for this service. A Medicare provider should accept the Medicare allowed 
amount as payment in full. In this case, the Plan is not responsible for paying the balance that remains after the 
Medicare allowed payment. Therefore, we decided that the Plan does not have to pay for a computed 
tomography scan provided on March 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on March 1, 2022. 
 
You asked the Plan to waive the copayment for an office visit. You say that you should not be responsible to 
pay this because this was for your annual physical. 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 $0 
copayment for an annual physical. The Plan contract also says if you receive services that address a medical 
condition during the same office visit additional cost-share may apply. 
 
 You have been asked to pay $10 for an office visit. This item/service falls within the office visit 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 an office visit provided on March 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 21, 2022. 
 
You asked the Plan to pay for the lab services. You say that this is a payable charge per Medicare guidelines. 
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 providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We looked at the file and Medicare rules. The claim at issue was billed with 22, an outpatient hospital place of 
service. The records show that the enrollee was receiving inpatient care at the time the services were provided. 
Based on this information, we decided that the Medicare rules for coverage have not been met. Therefore, we 
decided that the Plan does not have to pay for lab services provided on July 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (G0483) provided on January 3, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services were necessary and are supported in 
the medical record. 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 (G0483) provided on January 3, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from September 7, 2022, 
through September 9, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says that the acute inpatient hospital care provided 
was not medically necessary. 
 
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 these services. Our reviewer says that the 
documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer 
found that you presented to the emergency department (ED) on September 7, 2022 with near syncope. You 
were evaluated and found to have stable vital signs. Your electrocardiogram demonstrated non-sustained 
tachycardia. You were admitted to telemetry with sick sinus syndrome. You underwent a pacemaker insertion 
on September 8, 2022. You tolerated the procedure without complication, you were monitored and discharged 
home on September 9, 2022. The review indicates that the record showed that at the time of inpatient 
admission the admitting physician reasonably expected that your necessary hospital care (including earlier ED 
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 these services have been met. Therefore, we decided that the Plan has to pay for 
the acute inpatient hospital care provided from September 7, 2022, through September 9, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71271 billed for date of service May 21, 
2022. 
 
You asked the Plan to pay for procedure code 71271. You say that code 71271 was not bundled with any other 
procedure on the same date of service. The Plan denied your request. The Plan says payment for code 71271 is 
bundled into payment for code 71250. 
 
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 71271 
is a column II code to column I code 71250 with a modifier indicator of 0. The column II code is therefore not 
payable. The record shows code 71250 was processed for the same date of service and paid on June 16, 2022. 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 71271 billed for date of service May 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on October 14, 2021. 
 
You asked the Plan to pay for the lab services. 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 the lab services provided on October 14, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the peripheral revascularization procedure (CPT 
code(s): 37225, 37225, 37229, 37252, 37253, 36246, 36247, 36248, 76937, 75710). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says this service is not considered medically necessary for the enrollee's leg pain, and this is 
because the enrollee's leg pain does not appear to be coming from blockages in the arteries of the enrollee's 
legs. 
 
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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the documentation does not support the medical necessity of the treatments in question. The 
enrollee's symptoms occur with standing, and do not improve with rest strongly suggests alternative etiologies 
for leg pain. The duplex scan does not describe severe stenosis or occlusion. No pulse examination was 
performed. The provider has outlined a detailed conservative regimen, but this has not yet been attempted. 
 
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 pre-approve the peripheral revascularization procedure (CPT code(s): 37225, 37225, 37229, 37252, 
37253, 36246, 36247, 36248, 76937, 75710).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Opsumit. 
 
You asked the Plan to pre-approve Opsumit. You say that the requested drug is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the requested drug is considered self-administered. The 
Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also 
says the requested drug is not covered under Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Opsumit.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a microprocessor knee/foot. 
 
You asked the Plan to pre-approve a microprocessor knee/foot. The Plan denied your request. The Plan says 
this is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a fluid, pneumatic, or electronic/microprocessor knee 
(L5610, L5613, L5614, L5722, L5724, L5726, L5728, L5780, L5814, L5822, L5824, L5826, L5828, L5830, 
L5840, L5848, L5856, L5857, L5858) is covered for beneficiaries whose functional level is 3 or above. 
Medicare rules also 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 a microprocessor knee/foot. Our 
reviewer says that a microprocessor knee/foot is not medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee has a K3 foot and knee that is still under warranty. The physician documentation does not reveal damage or change that requires a new foot and knee. The physician 
documentation does not reveal extenuating factors why the enrollee now requires an integrated limb system 
with both a microprocessor knee and foot. Furthermore, a review of the Linx system indicates it has 
convenience features which are not medically necessary per Medicare criteria, such as a covered and magnetic 
charging point and a programming App. The requested Linx system exceeds the enrollee's medical needs and is 
not medically 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 a microprocessor knee/foot have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a microprocessor knee/foot.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary. The Plan 
denied your request. The Plan says admission to an IRF was denied as not meeting criteria, not medically 
necessary, and a lower level of care might be appropriate. 
 
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 does not require the intensity of services provided at an IRF. 
Specifically, the enrollee is not shown to require, or to be able to tolerate, fifteen hours per week of 
rehabilitative services with regular physician evaluation.  The enrollees care needs can be met 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-emergency transportation with a wheelchair van 
provided on July 12, 2022. 
 
You asked the Plan to pay for non-emergency transportation with a wheelchair van. You say that the hospital 
ordered transport with a wheelchair van and you did not have any control over what type of transportation was 
provided. The Plan denied your request. The Plan says non-emergency transportation with a wheelchair van is 
not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport 
services.  
 
The services you have asked the Plan to pay for are wheelchair van transport services. Therefore, we decided 
that the Plan does not have to pay for non-emergency transportation with a wheelchair van provided on 
July 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) for sacroiliac (SI) joint. 
 
You asked the Plan to pre-approve RFA of SI joint. You say that this service is medically necessary. The Plan 
denied your request. The Plan says the requested service is 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 RFA of SI joint. Our reviewer says that 
the requested RFA of SI joint is not considered medically reasonable and necessary in this case. Our physician 
reviewer found this procedure is considered experimental or investigational because of the wide variation in 
efficacy reported in the literature. Therefore, the reviewer found that the requested RFA of SI joint is not 
medically reasonable and 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 RFA of SI joint have not been met. Therefore, we decided that the Plan does not 
have to pre-approve radiofrequency ablation (RFA) for sacroiliac (SI) joint.