Persius/hicric huggingface dataset:
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 29 miles for a total of 79 miles of driving 
distance. 
 
You asked the Plan to pre-approve additional mileage. You say that your previous insurance covered your trips 
to this provider and you need follow up visits every day for treatment. The Plan denied your request. The Plan 
says this exceeds what your plan benefit covers. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when each one-way trip does not exceed 50 miles of driving 
distance.  We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an additional 29 miles for a total of 79 miles of driving distance.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says that the requested admission to an IRF does not meet 
criteria. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found a hip fracture is an IRF compliant diagnosis. Clinical documentation states that the enrollee has 
uncontrolled HTN and would warrant an inpatient hospitalization focused on rehabilitation. Clinical 
documentation states that the enrollee has functional impairments requiring both occupational therapy and 
physical therapy and would be able to tolerate an intensive rehabilitation regimen. The enrollee will benefit 
significantly in a prescribed period of time (14 days). 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care, first hour (99291) provided from January 7, 
2022, to January 9, 2022. 
 
You asked the Plan to pay for critical care. You say that these services were billed appropriately. The Plan 
denied your request. The Plan says these services are not supported as billed. 
 
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 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, the time spent providing 
these services is noted in the medical record. Based on this information, we decided that Medicare rules for 
coverage of critical care have not been met. Therefore, we decided that the Plan does not have to pay for 
critical care, first hour (99291) provided from January 7, 2022, to January 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Lumbar-sacral orthosis (L0637) provided February 14, 
2022. 
 
You asked the Plan to pay for the orthosis. You say that you disagree with the decision to deny and the records 
should support the service billed. The Plan denied your request. The Plan says the records do not support the 
service billed. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the orthosis have not been met. Therefore, we decided that the Plan does not have to pay for the 
Lumbar-sacral orthosis (L0637) provided February 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services provided on January 24, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed incorrectly. 
 
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 services have not been met. Therefore, we 
decided that the Plan does not have to pay for the genetic testing services provided on January 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve above-knee prosthetic legs and related supplies to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve prosthetic legs and related supplies. You say that the requested items are a 
medical necessity for you. The Plan denied your request. The Plan says rules for coverage for out-of-network 
care have not been met. 
 
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 
above-knee prosthetic legs and related supplies to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the VIA Disc NP allograft procedure. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the clinical value and effectiveness of the VIA Disc NP Allograft Procedure in the 
setting of lumbar intervertebral disc degeneration have not been demonstrated in the peer-reviewed 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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that Via Disc NP allograft is experimental., More research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met.  
 
 
  
Therefore, we decided that the Plan does not have to pre-approve the VIA Disc NP allograft procedure.
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 IRF care is medically reasonable and necessary for 
the enrollee's condition. The Plan denied your request. The Plan says rules for IRF care have not been met. 
 
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 that the patient was admitted for septic shock and atrial fibrillation. 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 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. In conclusion, 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. 
 
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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for a hospital outpatient clinic visit provided on November 18, 2021. 
 
You asked the Plan to pay for the hospital outpatient clinic visit. You say that all codes billed are valid and 
effective October 1, 2021, per ICD10. The Plan denied your request. The Plan says that the Plan's first decision 
to deny coverage and/or payment was right. 
 
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 any documentation to support their 
denial. Therefore, we decided that the Plan has to pay for a hospital outpatient clinic visit provided on 
November 18, 2021.  
 
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 prosthetic services provided on December 30, 2021. 
 
You asked the Plan to pay for the prosthetic services. You say that the services should be covered. The Plan 
denied your request. The Plan says 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. 
 
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 prosthetic services provided on December 30, 2021.
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require 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 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. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for debridement of mycotic nails and paring or cutting of benign 
hyperkeratotic lesion (e.g., corn or callus) provided on February 22, 2022. 
 
You asked the Plan to pay for debridement of mycotic nails and paring or cutting of benign hyperkeratotic 
lesion (e.g., corn or callus). You say that due to COVID-19 no other provider were able to treat residents in the 
facility. The Plan denied your request. The Plan says services from NP providers are not covered under open 
access unless preauthorized. 
 
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 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 debridement of mycotic nails and paring or cutting of benign 
hyperkeratotic lesion (e.g., corn or callus) provided on February 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a back injection procedure performed on 
February 16, 2022. 
 
You asked the Plan to waive the copayment for the injection. You say that your previous procedure did not 
have a copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing 
amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 
copayment for outpatient procedures and services in an outpatient hospital or ambulatory surgical center.  
 
You have been asked to pay a $250 copayment for the injection. The injection falls within the Outpatient 
Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 a back injection procedure performed on 
February 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional supplies, materials, and clinical staff time (99072) 
provided on April 5 to May 13, 2021. 
 
You asked the Plan to pay for additional supplies, materials, and clinical staff time. You say that the services at 
issue were billed correctly. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 We find that CPT code 99072 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99072 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of additional supplies, materials, and clinical staff time have not been met. Therefore, we decided that the Plan 
does not have to pay for additional supplies, materials, and clinical staff time (99072) provided on April 5 to 
May 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 88341, 88342, 88381, and 
88360 provided on July 20, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services were billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 88341, 88342, 88381, and 88360 are not supported in the medical record. Specifically, 
these codes have a professional component/technical component of 1. The claim was billed with a place of 
service of 22 (on campus-outpatient hospital). The professional interpretation was furnished in the same 
payment locality from where the technical component was furnished. The professional interpretation of a 
diagnostic test must be separately billed with modifier 26 by the interpreting physician. The documentation does not support that these services were billed correctly. Based on this information, we decided that Medicare 
rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not 
have to pay for the laboratory services coded 88341, 88342, 88381, and 88360 provided on July 20, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for chemotherapy drugs and administration 
provided from January 10, 2022, to February 21, 2022. 
 
You asked the Plan to waive the coinsurance for chemotherapy drugs and administration. You say that you 
didn't have to pay this in 2021 and don't understand why you must pay so much each time you have this done. 
The Plan denied your request. The Plan says the coinsurance applied is correct. At the time the claims were 
received you had not met your out-of-pocket maximum. You met your limit in the middle of your treatments 
and that is why you did not have to pay the full 20% coinsurance going forward. 
 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 20% 
coinsurance for each Medicare covered Part B chemotherapy drug and the administration of that drug.  
 
You have been asked to pay 20% coinsurance for chemotherapy drugs and administration. 
 
Date of Service Drug Allowed Amount Coinsurance Member Liability 
January 10, 2022 Administration $361.17 20% $72.23 
January 10, 2022 Chemotherapy 
Drugs 
$4,611.54 20% $922.31 
January 25, 2022 Administration $361.17 20% $72.23 
January 25, 2022 Chemotherapy 
Drugs 
$4,611.54 20% $922.31 
February 7, 2022 Administration $361.17 20% $72.23 
February 7, 2022 Chemotherapy 
Drugs 
$4,611.54 20% $922.31 
February 21, 2022 Administration $361.17 20% $72.23 
February 21, 2022 Chemotherapy 
Drugs 
$4,611.54 20% $54.15- Met OOP 
Max 
Total:    $3,110 
 
Chemotherapy drugs and administration falls within the Medicare Part B prescription drugs 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 coinsurance for chemotherapy drugs and administration provided from 
January 10, 2022, to February 21, 2022.