Persius/hicric huggingface dataset:
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 admission is a medical necessity. The Plan 
denied your request. The Plan says the admission was denied as it is not medically necessary because the 
enrollee did not appear to require intensive therapy services only provided in an IRF and their needs could be 
met 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. Our 
physician reviewer found the enrollee's functional status is amenable to home therapy services. The enrollee 
does not require intensive therapy for her chronic deconditioned state. Nor can she tolerate, participate in, or 
benefit from intensive therapy and does not require frequent physiatry oversight. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an emergency response system (S5161). 
 
You asked the Plan to pre-approve an emergency response system. You say that you need this device as you 
are always falling due to a stroke you had in the past. The Plan denied your request. The Plan says the 
requested device is not covered under your Medicare plan as it does not serve a diagnostic or therapeutic 
purpose. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve an emergency response system (S5161).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998) 
provided on May 24, 2022. 
 
You asked the Plan to pay for the ambulance response. You say that this service should be covered under your 
ambulance benefit. The Plan denied your request. The Plan says this service is not covered when there is no 
transport. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 The ambulance company did not provide transport services on May 24, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
The trip report in this case shows that the enrollee refused transport to the hospital and thus the wavier criteria 
is not met. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, 
no transport (A0998) provided on May 24, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a PET scan to be provided out-of-network. You say that the enrollee wants 
the service to be done at this provider. The Plan denied your request. The Plan says the request for service is 
not urgent and can be done within network. 
 
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 
a positron emission tomography (PET) scan to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the group three power wheelchair and power seat 
elevation system, to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the group three power wheelchair and power seat elevation system. You say 
that the items are medically necessary. The Plan denied your request. The Plan says there are in-network 
providers available for this item. 
 
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 
the group three power wheelchair and power seat elevation system, 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 waive the copayment for inpatient hospital care provided on April 
11, 2022, to April 17, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you are disputing the share 
cost. 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 $345 
copayment per day for days 1 to 5 for inpatient hospital care. This inpatient hospital stay lasted 3 days, 
resulting in a copayment amount of $1,035 ($345 per day for 3 days = $345). 
 
You have been asked to pay $345 copayment per day for days 1 to 5 for inpatient hospital care. This 
item/service falls within the inpatient hospital care benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for inpatient hospital care provided on April 11, 2022, to April 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87640 billed for date of service September 6, 
2022. 
 
You asked the Plan to pay for procedure code 87640. You say that this service was reported correctly. The Plan 
denied your request. The Plan says payment for code 87640 is bundled into payment for code 87641. 
 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 87640 
is a column II code to column I code 87641. 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 procedure code 87640 billed for date of service September 6, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pontic-porcelain fused to high noble metal (D6240) 
for tooth #20. 
 
You asked the Plan to pre-approve the dental service. You say that you cannot chew on your right side. The 
Plan denied your request. The Plan says the x-rays show the enrollee has other teeth missing in the same arch. 
 
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. The Plan covers the dental 
service when the services are medically necessary and reasonable.  
 
  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 dental service. Our reviewer says 
that the pontic-porcelain fused to high noble metal (D6240) for tooth #20 is not medically necessary. Our 
physician reviewer found that the documentation provided does not meet the criteria for coverage for a pontic 
(D6240) replacing missing tooth #20. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental service have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a pontic-porcelain fused to high noble metal (D6240) for tooth #20.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transit system and a privacy flap matrix back 
(K0108x2). 
 
You asked the Plan to pre-approve wheelchair accessories. You say that the requested accessories are necessary 
for the enrollee. Additional information has been submitted to show why the accessories should be covered. 
The Plan denied your request. The Plan says Medicare covers durable medical equipment (DME) only when 
needed in the home. While an enrollee may incidentally use DME outside of the home, the criterion for which 
it is covered by Medicare is that there must be an in-home need. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a transit system and a privacy flap matrix back (K0108x2).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 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 an IRF admission 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 enrollees medical and rehabilitation needs do not require the intensive 
interdisciplinary approach provided in acute inpatient rehabilitation, and they do not require the intensity of 
therapies provided in acute inpatient rehabilitation. Given the enrollees level of fatigue, it also is unlikely that she can benefit from the intensity of therapies on acute inpatient rehabilitation. 
 
Therefore, the acute inpatient rehabilitation admission 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visit provided on 
September 6, 2022. 
 
You asked the Plan to waive the copayment for specialist office visit. You say that you are disputing the share 
cost. 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 $30 
copayment for podiatry services.  
 
You have been asked to pay $30 copayment for a specialist office visit. This item/service falls within the 
podiatry services 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 specialist office visit 
provided on September 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous passive motion device. 
 
You asked the Plan to pre-approve the continuous passive motion device. You say that this device is medically 
necessary. The Plan denied your request. The Plan says insufficient information has been provided. 
 
The Plan must follow Medicare rules. The rules say that CPM devices are covered only if use of the device 
began within two days of receiving total knee replacement surgery.  
 
Records show that total knee replacement surgery was received on October 12, 2022. More than two days have 
elapsed following total knee replacement surgery. Additionally, no recent clinical records were provided to 
support the request. Therefore, we decided that the Plan does not have to pre-approve a continuous passive 
motion device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Via Disc allograft procedure. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee has tried and failed 
conservative treatment. The Plan denied your request. The Plan says the clinical effectiveness has not been 
demonstrated in literature. 
 
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 requested services. Our physician 
reviewer found that the enrollee has had discogenic low back pain for greater than 6 months. His symptoms 
include pain with extension flexion and average vas score of 7 out of 10 and pain radiating down bilateral 
extremities. The enrollee has tried and failed greater than 6 months of conservative treatment in the form of 
physical therapy. Continued home exercise program and lumbar epidural injections with little lasting relief. 
The requested service is considered an experimental/investigational procedure at this time. Therefore, the 
request is deemed 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Via Disc allograft procedure.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service July 15, 
2022. 
 
You asked the Plan to pay for procedure code 76705. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for 
code 93976. 
 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 procedure code 76705 billed for date of service July 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve ventilator. You say that this is medically necessary over positive airway 
pressure to reduce respiratory distress and anticipated pulmonary decline. The Plan denied your request. The 
Plan says a ventilator is not covered by Medicare for this purpose. 
 
The Plan must follow Medicare rules. Medicare rules say that ventilator products used to provide continuous or 
bilevel positive airway pressure therapy, regardless of the underlying medical condition, are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
home ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visit provided on May 8, 2022. 
 
You asked the Plan to waive the copayment for office visit. You say that you are disputing the share cost. 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 $10 
copayment for physician/practitioner services, including doctor's office visits.  
 
You have been asked to pay $10 copayment for an office visit. This item/service falls within the 
physician/practitioner services, including doctor's office visits benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for office visit provided on May 8, 2022.  
 Your complaint about lack of discussion with your doctor is not a valid appeal for medical coverage. This part 
of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 15, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that the records support this service. The Plan denied your 
request. The Plan says there is no prior authorization or referral on file. 
 
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 June 15, 2021, by an 
out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve a bypass graft (35656) and inpatient admission. 
 
You asked the Plan to pre-approve a bypass graft and inpatient admission. You say that the services are 
medically necessary. The Plan denied your request. The Plan says that the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 pre-approve a bypass graft and inpatient admission. 
Our reviewer says that the requested items/services are considered medically reasonable and necessary in this 
case. Our physician reviewer found the documentation supports the medical necessity of right lower extremity 
arterial bypass, a procedure that will require hospital admission. There is documentation that the enrollee has 
severe arterial occlusive disease of the right lower extremity with associated rest pain and severely diminished 
ankle-brachial indexes (ABI). These findings are all consistent with limb threatening ischemia necessitating 
treatment. The enrollee has already undergone diagnostic angiography where it was demonstrated that the 
lesion could not be treated through an endovascular approach. In this setting, surgical bypass is both reasonable 
and 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 bypass graft and inpatient admission have been met. Therefore, we decided 
that the Plan has to pre-approve a bypass graft (35656) and inpatient admission.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a capsule endoscopy (91110). 
 
You asked the Plan to pre-approve a capsule endoscopy. You say that the service is medically necessary. The 
Plan denied your request. The Plan says your records do not show that you have had a recent colonoscopy that 
failed to identify a bleeding source. 
 
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 a capsule endoscopy. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has not had a upper and lower GI endoscopies within the past 12 months  
esophagogastroduodenoscopy (EGD) and colonoscopy) that have failed to identify a bleeding source. 
 
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 capsule endoscopy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a capsule endoscopy (91110).