Persius/hicric huggingface dataset:
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 the patient has had a severe decline in function. The 
Plan denied your request. The Plan says that although the member would benefit from ongoing physical and 
occupation therapy, this could 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 
complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for congestive heart 
failure, hematoma of the knee and a renal mass. The enrollees medical problems are stable. There are no 
complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including 
either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the 
patient has a need for physical and/or occupational therapy, there is no documentation of a need for an 
intensive rehabilitation program. 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. 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 23, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services were not 
billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that if one laboratory procedure evaluates multiple 
genes using a next generation sequencing procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, ultianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis CPT code.  
 
We looked at the file and Medicare rules. In this case, the requested genetic testing was billed with multiple 
codes. Per Medicare rules, the testing should be reported with one unit of one CPT code. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we 
decided that the Plan does not have to pay for the genetic testing provided on March 23, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on November 11, 2021. 
 
You asked the Plan to pay for an office visit. The Plan denied your request. The Plan says this provider has 
opted out of Medicare and is not a Medicare certified provider. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for an office 
visit provided on November 11, 2021.
Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve the services. We decided that the Plan does not have to pre-
approve the bone scan.  
 
You asked the Plan to pre-approve the services. You say that this is medically necessary as you are in pain. The 
Plan says that the doctor's note did not mention anything about a growth in the lung. 
 
We decided that the Plan has to pre-approve the CT scan of the chest.  
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
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 for the CT scan of the chest. Our reviewer says that the 
CT scan was medically reasonable and necessary. Our physician reviewer found that the use of CT to evaluate the ribs and chest wall due to continued pain after 
a fall is very reasonable. Ribs are well analyzed in this way. Thus, the CT scan of the chest is indicated. 
 
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 been met. Therefore, we decided that the Plan has to pre-
approve the CT scan of the chest.  
 
We also decided that the Plan does not have to pre-approve the bone scan. 
 
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 for the bone scan. Our reviewer says that the requested 
bone scan is not medically reasonable or necessary. Our physician reviewer found that without a known 
malignancy, the use of a radionuclide bone scan is not reasonable if the chest CT is approved. The CT will 
show even small non-displaced fractures as you likely have osteoporosis due to chronic steroid use. The bone 
scan would be redundant and should not be approved.  
 
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 bone scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the bone scan. 
 
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 the laboratory services provided on September 20, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
 
 The Plan must follow Medicare rules. Medicare rules say that 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 laboratory 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 laboratory services provided on September 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99204), laboratory service (83036), and the 
collection of a capillary blood specimen (36416) rendered by the out-of-network (OON) provider on  
January 18, 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 the services were rendered by an out of 
network provider, without prior authorization. 
 
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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. 
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the office visit (99204), laboratory service (83036), and the collection of a 
capillary blood specimen (36416) rendered by the out-of-network (OON) provider on January 18, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care, first hour (99291) provided on July 27, 2021. 
 
You asked the Plan to pay for critical care. You say that this service is supported in the record. The Plan denied 
your request. The Plan says a National Correct Coding Initiatives (NCCI) Procedure to Procedure (PTP) edit 
exists between 31500 and 99291. This PTP edit has a modifier indicator of 1, meaning modifiers associated 
with NCCI are allowed. However, an appropriate modifier was not billed with this PTP code edit. This service 
was not billed as required by Medicare coding regulations. 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 99291 
is a column II code to column I code 31500. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for critical care, first hour (99291) provided on July 27, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia (J0897). 
 
You asked the Plan to pre-approve the Prolia. You say that Prolia is medically necessary. The Plan denied your 
request. The Plan says a trial of oral bisphosphonates is required before alternatives can be considered. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
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 Prolia. Our reviewer says that Prolia 
is not medically necessary. Our physician reviewer found the record does not show a trial of the plan preferred 
drugs or any reason they would be unsafe or ineffective for the enrollee. 
 
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 Prolia have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Prolia (J0897).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0651, E0667). 
 
You asked the Plan to pre-approve the pneumatic compression device. You say that the device is medically 
necessary. The Plan denied your request. The Plan says [Enter plan denial rationale, e.g. "...rules for SNF care 
have not been met."] 
 
The Plan follows Medicare rules. Medicare rules say that only when no significant improvement has occurred 
in the most recent four weeks may the lymphedema be considered unresponsive to conservative therapy, and 
coverage for a pneumatic compression device considered. 
 
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 pneumatic compression device. Our 
reviewer says that the pneumatic compression device is not medically necessary. Our physician reviewer found 
the documentation does not show that there was a full four week trial of conservative treatment. 
 
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 pneumatic compression device have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a pneumatic compression device (E0651, E0667).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on February 1, 
2022. 
 
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 an appropriate modifier was not billed with this edit. 
 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 76705 
is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for imaging services provided to the enrollee on February 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a CGM. You say that the requested CGM is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet criteria for the requested CGM. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 a CGM. Our reviewer says that the 
enrollee does not meet criteria for the requested CGM. Our physician reviewer found the record indicates that 
the enrollee has diabetes.  The record does not indicate that the enrollee is insulin-treated with multiple (three 
or more) daily administrations of insulin or a continuous subcutaneous insulin infusion (CSII) pump. The elements of the coverage criteria are not satisfied. The requested service is not 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 a CGM have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Volara device. 
 
You asked the Plan to pre-approve the Volara device. You say that this is medically necessary. The Plan denied 
your request. The Plan says that Medicare states that intrapulmonary percussive ventilators such as the Volara 
device have not been demonstrated to be reasonable and necessary in the home setting. 
 
The Plan must follow Medicare rules. Medicare rules say that an intrapulmonary percussive ventilator (IPV) 
has not been demonstrated to be reasonable and necessary in the home setting and that it will be denied as not 
medically necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Volara device have not been met. Therefore, we decided that the Plan does not have to pre-
approve the Volara device.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Psychiatric Diagnostic Evaluation with Medical Services 
provided on December 31, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for Psychiatric Diagnostic Evaluation with Medical Services. You say that that it 
isn't your responsibility to obtain prior authorization. The Plan denied your request. The Plan says the provider 
is out-of-network and authorization is required prior to an out-of-network visit. 
 
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 Psychiatric Diagnostic Evaluation with Medical 
Services provided on December 31, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the positron emission tomography (PET) scan (78815), 
laboratory service (88321), office visit (99204), the fluorodeoxyglucose, diagnostic, per study dose (A9552), 
and the genetic counseling (96040) rendered by the out-of-network (OON) providers from October 5, 2021, 
October 22, 2021. 
 
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 the services were rendered by out-of-network 
providers. There were in-network providers available to render the requested services.  
 
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 providers in this case are not network providers with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. 
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the positron emission tomography (PET) scan (78815), laboratory service 
(88321), office visit (99204), the fluorodeoxyglucose, diagnostic, per study dose (A9552), and the genetic 
counseling (96040) rendered by the out-of-network (OON) providers from October 5, 2021, October 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on December 21, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you weren't aware that the provider is OON and that 
you can't afford it. The Plan denied your request. The Plan says the provider is out-of-network, an authorization 
is required, and it was determined these services were not urgent or emergent. 
 
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 an office visit provided on December 21, 2021 by 
an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on December 15, 2021, by 
an OON provider. 
 
You asked the Plan to pay for the laboratory services. You say that the referring provider sends the specimens 
to your laboratory to get processed and you would like the claim reprocessed for payment. The Plan denied 
your request. The Plan says the rendering and referring providers are both OON providers and there was no 
approved authorization. Also, the service rendered was not urgent or emergent. 
 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 laboratory services provided on December 15, 
2021, by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient podiatry office visit (99212, 99213) provided 
on February 23, 2021 to January 18, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the provider did not advise you that he was not a 
participating provider. You would have found a different doctor if you had known. The Plan denied your 
request. The Plan says enrollees must receive their medical services from an in-network provider with the 
exception being urgent or emergent services. Non-emergent services with non-contracted providers require 
prior authorization before services being rendered. 
 
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 outpatient podiatry office visit (99212, 99213) 
provided on February 23, 2021 to January 18, 2022 by an out-of-network (OON) provider.