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

 
We decided that the Plan does not have to pre-approve an endocrinology second opinion to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the OON endocrinology consultation. You say that you have been evaluated 
for a thyroid nodule, and after an ultrasound, you received something recommending that you get a biopsy. 
You think this may not be necessary, and you wish to get a second opinion from the OON provider. The Plan 
denied your request. The Plan says the Plan's network has multiple other endocrinologists who can offer an 
independent second opinion regarding the need for a biopsy. There is no medical need for this to be provided 
OON. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an endocrinology second opinion to be provided 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 the records provided support the need for care in an 
IRF. The Plan denied your request. The Plan says IRF Care is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for surgical repair of an ankle fracture and was discharged home on October 24, 2022. There is 
progressive weakness despite home health services. The enrollee's medical problems are stable. There are no 
complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
While the medical record supports a need for physical and/or occupational therapy, there is no documented 
need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 
There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. 
 
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 IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that before your fall you were totally independent 100% 
and did not need a walker or cane or any kind of accessories. The Plan denied your request. The Plan says the 
documentation fails to indicate that you have a diagnosis that is appropriate for acute inpatient rehabilitation 
only. 
 
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 your nursing, medical and rehabilitation needs do not require 
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
surgical repair of a hip 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 therapy and/or occupational 
therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be 
provided a in a different level of care. There is not a reasonable expectation that you 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 IRF admission and services.
Appeal type: Hospice
Decision: Favorable

 
We decided that the Plan has to pay for the hospice care provided in a nursing long term care facility (ltc) or 
non-skilled nursing facility (nf) provided from March 4, 2022, to March 31, 2022. 
 
You asked the Plan to pay for the hospice care. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says that the enrollee was enrolled in hospice at the time 
these services were rendered. 
 
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. Specifically, the Plan has not provided us with proof of hospice enrollment. 
Therefore, we decided that the Plan has to pay for the hospice care provided in a nursing long term care facility 
(ltc) or non-skilled nursing facility (nf) provided from March 4, 2022, to March 31, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on July 26, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for lab testing. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says the enrollee must receive their care from a network provider (for more information 
about this, see Section 2 in this chapter). In most cases, care the enrollee receives from an out-of-network 
provider (a provider who is not part of our plans network) will not be covered. 
 
 
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 lab testing provided on July 26, 2022, by an out-
of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hematopathology services provided to the enrollee on March 
1, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says all treatment details are needed. 
 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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the provided records do not document that an alternative laboratory or clinical test to definitively 
diagnose the disorder/identify the condition were unavailable or results were clearly equivocal, and the 
provided test was a clinically valid test, based on published peer reviewed medical literature, and the testing 
assay(s) were Food and Drug Administration (FDA) approved/cleared or if LDT (lab developed test) or LDT 
protocol or FDA modified test(s) the laboratory documentation supported the assay(s) analytical validity and 
clinical utility, and the number of genes tested were reasonable and necessary to establish a diagnosis, and the 
patient had not previously received genetic testing for the disease/condition, as required by the LCD.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for hematopathology services provided to the enrollee on March 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient evaluation and management (EM) service 
provided on April 4, 2022. 
 
You asked the Plan to pay for the EM service as billed. You say that this should be paid as a corrected claim 
was submitted to bill 99214 instead of 99233 to reflect that the enrollee was not yet inpatient on that date. The 
Plan denied your request. The Plan says this outpatient code was incorrectly billed with an inpatient place of 
service code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
Though the claim was corrected to reflect an outpatient EM service, the place of service (POS) code was 
reported as 21 which is inpatient hospital. Outpatient EM codes are not payable when billed with an inpatient 
POS. Based on this information, we decided that Medicare rules for coverage of the EM service as billed have 
not been met. Therefore, we decided that the Plan does not have to pay for the outpatient evaluation and 
management (EM) service provided on April 4, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve upgraded components including an Ossur Mach Knee 
(L5828 and L5999) for the authorized prosthetic leg. 
 
You asked the Plan to pre-approve upgraded components including an Ossur Mach Knee for the authorized 
prosthetic leg. You say that the requested items/services are considered medically reasonable and necessary in 
this case. The Plan denied your request. The Plan says the requested items/services are not considered 
medically reasonable and necessary in this case. 
 
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 upgraded components including an 
Ossur Mach Knee for the authorized prosthetic leg. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation 
doesn't support the medical necessity for the requested knee.  The documentation indicates the member's 
weight is more than what can be supported by the requested knee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of upgraded components including an Ossur Mach Knee for the authorized 
prosthetic leg have not been met. Therefore, we decided that the Plan does not have to pre-approve upgraded 
components including an Ossur Mach Knee (L5828 and L5999) for the authorized prosthetic leg.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a transcutaneous electrical nerve stimulation (TENS) device 
(E0730) and a heating pad system (E0221) provided by a chiropractor on July 20, 2022. 
 
You asked the Plan to pay for a TENS device and a heating pad system. You say that these items are covered 
by Medicare. The Plan denied your request. The Plan says these items are not covered when provided by a 
chiropractor. 
 
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 items/services at issue are not manual manipulation of the spine. Therefore, we 
decided that the Plan does not have to pay for a transcutaneous electrical nerve stimulation (TENS) device 
(E0730) and a heating pad system (E0221) provided by a chiropractor on July 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on July 14, 2022, billed with 
code 81225. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like this claim reprocessed and 
approved for payment. 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 14, 2022, billed with code 81225.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection between wheelchair controller 
and two or more power seating system motors (E2311), a harness (E2313) and an expandable controller 
(E2377). 
 
You asked the Plan to pre-approve wheelchair accessories. You say that the requested items are medically 
necessary. The Plan denied your request. The Plan says the upgraded electronics are not medically necessary. 
They are necessary when there is a medical need to control three or more power options through the joystick. 
 
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 wheelchair accessories. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found a group 3 power wheelchair can be covered if the medical necessity for a PWC is met 
and if the disorder causing the mobility limitation is a neurological condition, myopathy or congenital skeletal 
deformity.  The enrollee also must require a drive control interface, power tilt or a power recline seating system 
and if there has been a specialty evaluation that was performed by a licensed/certified medical professional, 
such as a physical or occupational therapist. An expandable controller is an electronic system that is capable of 
accommodating one or more additional features and can operate 3 or more powered seating options. In this 
case, the enrollee has a neurologic disorder with functional deficits. Criteria for a power wheelchair are 
met. 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 wheelchair accessories have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an electronic connection between wheelchair controller and two or more power 
seating system motors (E2311), a harness (E2313) and an expandable controller (E2377).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient mental health services after December 22, 
2022. 
 
You asked the Plan to pre-approve inpatient mental health services. You say that these services continue to be 
medically reasonable and necessary. The Plan denied your request. The Plan says the continuation of inpatient 
mental health care is not medically reasonable and necessary. 
 The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient mental health services. Our 
reviewer says that the requested inpatient mental health services after December 22, 2022, are not medically 
reasonable and necessary. Our physician reviewer found that the enrollee is a 67-year-old male was admitted to 
the acute inpatient psychiatric hospitalization on December 19, 2022, with Major Depressive Disorder, 
Recurrent, Severe without Psychotic Features. Based upon review the records provided it was not expected this 
enrollee would improve in a reasonable period of time beyond the dates in question as he was not showing any 
dangerousness to self or others, auditory or visual hallucinations and without aggressive behaviors while not 
showing any acute threats of safety. It did not appear medically necessary and reasonable to have psychiatric 
care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question 
as he did not have any suicidal or homicidal thoughts, auditory or visual hallucinations or abnormal behaviors.  
 
In this case, this patient does not meet the criteria for treatment in an acute inpatient mental health treatment 
beyond the date in question of December 23, 2022, forward and could be treated in a lesser restrictive 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 inpatient mental health services have not been met. Therefore, we decided that 
the Plan does not have to pre-approve inpatient mental health services after December 22, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve three (3) additional home care visits. 
 
You asked the Plan to pre-approve home health services. You say that the provider has submitted medical 
records for reconsideration of the authorization denial of additional home care visits. The enrollee lives in 
assisted living, and they do not do wound care. The Plan denied your request. The Plan says the services are not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the enrollee 
does not have documented skilled nursing needs (i.e., IVs, complex wound care, new ostomy, new TFs). The 
care required is unclear (twice or thrice weekly). There is no clear evidence as to why the enrollee, family, 
facility staff and wound clinic are unable to cumulatively provide the required 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve three (3) additional home care visits.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for needle electromyography (95870) provided on May 16, 
2022. 
 
You asked the Plan to pay for needle electromyography. You say that this was billed with a modifier for 
separate payment. The Plan denied your request. The Plan says this is not documented. 
 
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 95870 is needle electromyography; limited study of 
muscles in 1 extremity or non-limb (axial) muscles (unilateral or bilateral), other than thoracic paraspinal, 
cranial nerve supplied muscles, or sphincters. 
 
We find that CPT code 95870 is not supported in the medical record. Specifically, this service is not documented in the submitted records. Based on this information, we decided that Medicare rules for coverage 
of needle electromyography have not been met. Therefore, we decided that the Plan does not have to pay for 
needle electromyography (95870) provided on May 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intra-socket biological dressing (D7922). 
 
You asked the Plan to pre-approve intra-socket biological dressing. You say that you need this extraction done 
as soon as possible. The Plan denied your request. The Plan says the requested dental service is not a covered 
benefit. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve intra-
socket biological dressing (D7922).