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. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is ready to discharge from the hospital 
but cannot go home. The Plan denied your request. The Plan says the denial of IRF care is correct. 
 
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. While the enrollee may need physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on July 26, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says payment is 
included in the facility payment. 
 The Plan must follow Medicare rules. Medicare rules say that payment for inpatient SNF laboratory services is 
included in the SNF PPS payment.  
 
We looked at the file and Medicare rules. In this case, payment for the requested lab services is included in the 
SNF PPS payment. The services are not separately payable. Based on this information, we decided that 
Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab services provided on July 26, 2022.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay $60 more for the single vision lenses and anti-reflective coating. We 
decided that the Plan does not have to pay more than the $150 allowance for the single vision lenses and anti-
reflective coating.  
 You asked the Plan to pay for the single vision lenses (V2100) and anti-reflective coating (V2750) purchased 
on June 7, 2022. You say that the treating provider talked you into getting glasses during your routine eye 
exam. You also say that you would have gone without getting the glasses if you had known you would have to 
pay for them because they are basically readers. The Plan says that this claim processed correctly in accordance 
with your vision benefit. 
 
We decided that the Plan has to pay $60 more for the single vision lenses and anti-reflective coating.  
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers up to $150 per calendar year for services provided by a Plan-approved Vision Care 
participating provider. 
 
We looked at the file and the Plan's rules. The contract says you have a $150 allowance for eyewear purchased 
from a participating provider. The record shows that only $90 of this balance was used, and no documentation 
was provided showing your allowance had been exhausted. Based on this information, we decided that the 
Plan's rules for coverage of the single vision lenses and anti-reflective coating have been met. Therefore, we 
decided that the Plan has to pay $60 more for the single vision lenses and anti-reflective coating.  
 
We also decided that the Plan does not have to pay more than the $150 allowance for the single vision 
lenses and anti-reflective coating. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers up to $150 per calendar year for services provided by a Plan-approved Vision Care 
participating provider. 
 
We looked at the file and the Plan's rules. Specifically, the after the additional $60 payment made by the Plan 
for these services, your $150 allowance will be exhausted. Based on this information, we decided that the 
Plan's rules for coverage of the single vision lenses and anti-reflective coating have not been met. Therefore, 
we decided that the Plan does not have to pay more than the $150 allowance for the single vision lenses and 
anti-reflective coating. 
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on October 26, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the 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 services provided on October 26, 2021, by an out-of-network 
(OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A0425 billed for date of service June 22, 
2022. 
 
You asked the Plan to pay for procedure code A0425. You say that this should be paid for. The Plan denied 
your request. The Plan says the number of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.   
In this case, the MUE for CPT code A0425 is 250. The MAI value for this code is 2. You billed 283 units of 
this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code A0425 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code A0425 billed for date of service June 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Jazzy elite HD power wheelchair. 
 
You asked the Plan to pre-approve a Jazzy elite HD power wheelchair. You say that the medical records 
provided support the need for the requested wheelchair. The Plan denied your request. The Plan says the 
request for a brand specific power wheelchair is not medically necessary. The Plan says that there is no 
documentation as to why this particular brand of power wheelchair is medically necessary over a power 
wheelchair with a Medicare approved code. 
 The Plan follows Medicare rules. Medicare rules say that specific brand name items are only covered when 
medical records demonstrate the reason why the specific brand or mode of delivery is necessary to avoid an 
adverse medical outcome. 
 
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 Jazzy elite HD power wheelchair. Our 
reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee has 
ruptured tendons in her lower extremities. She is unable to walk. The records provided do not show any 
features that the brand name product has that are necessary to avoid an adverse medical outcome. The brand 
name product 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 Jazzy elite HD power wheelchair have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a Jazzy elite HD power wheelchair.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to provide a positron emission tomography (PET) scan. 
 
You asked the Plan to provide a positron emission tomography (PET) scan. You say that you would like to 
request reconsideration of the denied authorization. The Plan denied your request. The Plan says that the 
service is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that PET 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 to provide a positron emission tomography (PET) scan. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found the request for a 
PET scan is 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 a positron emission tomography (PET) scan have been met. Therefore, we 
decided that the Plan has to provide a positron emission tomography (PET) 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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the echocardiography provided on August 22, 2022. 
 
You asked the Plan to pay for the echocardiography. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services rendered are not payable. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the echocardiography provided on August 22, 2022.
Appeal type: Hospice
Decision: Favorable

 
We decided that the Plan has to pay for the hospital discharge day management (99239) provided on June 17, 
2022. 
 
You asked the Plan to pay for the evaluation and management service. You say that the service in this case 
should be paid. The Plan denied your request. The Plan says that the enrollees claim would be covered under 
Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the 
last day of the month in which hospice is revoked. The Plan also says it is the providers responsibility to verify 
the enrollees coverage before rendering services and to know proper billing procedures for a Medicare 
Advantage member on hospice. 
 
The Plan must follow Medicare rules. Medicare rules say that the plan that covered the enrollee at the 
beginning of an inpatient stay is responsible for the entire stay. If there is a change in coverage during the stay, 
the new Plan is not responsible for inpatient hospital care until after the date of discharge.  
 
The enrollee's Medicare Advantage plan was the Plan of record at the time of the inpatient stay related to the 
issue in this appeal. Although the record shows that the enrollee was enrolled in the Medicare Hospice benefit 
on the date of service in this case, Original Medicare is not responsible for coverage of the evaluation and 
management service until after this stay ended. Therefore, we decided that the Plan has to pay for the hospital 
discharge day management (99239) provided on June 17, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of a Barostim Neo system (baroflex 
stimulation device). 
 
You asked the Plan to pre-approve Barostim. You say that this device contributes to improving the symptoms 
of heart failure. The Plan denied your request. The Plan says this device is not sufficiently supported by 
research. 
 
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 Barostim. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there remains an absence of randomized, blinded clinical studies examining long-term clinical 
outcomes to establish the value of Barostim Neo in patient management. As a result, this would not be 
considered medically reasonable and necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Barostim have not been met. Therefore, we decided that the Plan does not have 
to pre-approve insertion of a Barostim Neo system (baroflex stimulation device).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen therapy (HBOT). 
 
You asked the Plan to pre-approve HBOT. You say that the enrollee needs oxygen therapy. The Plan denied 
your request. The Plan says the requested hyperbaric oxygen therapy is not medically reasonable or necessary. 
 
The Plan follows Medicare rules. Medicare rules say that the use of HBO therapy is covered as adjunctive 
therapy only after there are no measurable signs of healing for at least 30-days of treatment with standard 
wound therapy and must be used in addition to standard wound care. 
 
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 HBOT. Our reviewer says that the 
requested HBOT is not medically necessary. Our physician reviewer found the provided documentation does 
not show any conventional treatment (alum instillation, aminocaproic acid). Therefore, the reviewer found that 
the requested HBOT is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of HBOT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve hyperbaric oxygen therapy (HBOT).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 7, 2022, billed with 
codes 81210, 81235, 81272, 81275, 81276, 81292, 81295, 81298, 81301, 81311, 81317, 81321 and 81194. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was medically 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. In addition, this claim was billed with an incorrect place of service code. 
 
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 
June 7, 2022, billed with codes 81210, 81235, 81272, 81275, 81276, 81292, 81295, 81298, 81301, 81311, 
81317, 81321 and 81194.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88305 billed for date of service November 9, 
2021. You asked the Plan to pay for procedure code 88305. You say that medical records were submitted. The Plan 
denied your request. The Plan says payment for code 88305 is bundled into payment for code G0416. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code.  
 
In this case, we have confirmed that code 88305 is a column II code to column I code G0416. The medical 
records do not show that the service billed with the -59 modifier was a distinct procedural service. 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 procedure code 88305 billed for date of service November 9, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the removal of external fixation system and the debridement 
services provided on June 5, 2022. 
 
You asked the Plan to pay for the removal of external fixation system and the debridement services. You say 
that you disagree with the Plan's denial. The Plan denied your request. The Plan says the services are not 
payable for this provider. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
 In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of 
practitioners. Therefore, we decided that the Plan does not have to pay for the removal of external fixation 
system and the debridement services provided on June 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 enrollee's ongoing medical care 
warrants an LTACH level of care to achieve a safe and sustainable discharge. The Plan denied your request. 
The Plan says admission requirements to the LTACH have not been met and enrollee's medical needs are being 
met in the current acute setting. 
 
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 does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. The health plan has approved ongoing care in the current 
acute care setting. The requested LTACH services are not medically necessary. Reasonable and appropriate 
services for the enrollees diagnosis and condition can be safely and effectively furnished only on an inpatient 
basis. 
 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a binaural dispensing fee (V5160) provided on July 6, 2022. 
 
You asked the Plan to pay for a binaural dispensing fee (V5160). You say that you were not notified that the 
amount of $1,650 was not going to be covered by insurance. You also say that per the hearing aid purchase 
agreement, that amount was under the insurance program and was submitted to insurance. The Plan denied 
your request. The Plan says this service is a covered benefit, but the enrollee has exceeded the limits set in the 
subscriber's agreement. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for up 
to $2,000 for hearing aids every 3 years.  
 
We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of a binaural dispensing fee (V5160) have not been met. Therefore, we decided that the Plan does not 
have to pay for a binaural dispensing fee (V5160) provided on July 6, 2022.