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. The Plan denied your request. The Plan says the enrollee's needs 
can 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 medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit (99336) provided on 
November 26, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that the service at issue was a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment 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 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 a domiciliary or rest home visit (99336) provided 
on November 26, 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 drug testing services provided on February 3, 2022. 
 
You asked the Plan to pay for the testing services. You say that the records are sufficient for the services 
provided. The Plan denied your request. The Plan says the code remains not supported. 
 
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 G0483 is definitive drug testing for 22 or more drug 
classes. We find that CPT code G0483 is not supported in the medical record. Specifically, the records do not 
show that 22 or more drug classes were ordered or tested. There is a more comprehensive code available to 
describe the services provided.  Based on this information, we decided that Medicare rules for coverage have 
not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided 
on February 3, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve direct skilled nursing services of a licensed practical 
nurse (LPN) (G0300), home health aide (HHA) services (G0156), and direct skilled nursing services of a 
registered nurse (RN) (G0299). 
 
You asked the Plan to pre-approve direct skilled nursing services of an LPN and RN and HHA services. The 
Plan denied your request. The Plan says these services are not medically necessary. 
 
  The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve direct skilled nursing services of an 
LPN and RN and HHA services. Our reviewer says that home health skilled nursing services, and associated 
HHA services, are not medically necessary or reasonable. Our physician reviewer found the enrollee does not 
have documented skilled nursing needs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of direct skilled nursing services of an LPN and RN and HHA services have not 
been met. Therefore, we decided that the Plan does not have to pre-approve direct skilled nursing services of a 
licensed practical nurse (LPN) (G0300), home health aide (HHA) services (G0156), and direct skilled nursing 
services of a registered nurse (RN) (G0299).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT 
code(s): 22869 and 22870). 
 
You asked the Plan to pre-approve the services. You say that the procedure will resolve your back issues 
because you are in severe pain on your back. The Plan denied your request. The Plan says the documentation 
shows that you are not an appropriate candidate for the specific indication for which the device was Food and 
Drug Administration (FDA) approved for. 
 
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 items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the Vertilfex device 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 Vertiflex superion device placement surgery (CPT code(s): 22869 and 22870).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT 
code 22869). 
 
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says unproven and not medically necessary procedures are not covered by Medicare due to 
insufficient evidence of efficacy. 
 
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 service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Vertilfex device is experimental. More research is needed to show safety and efficacy. 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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Vertiflex superion device placement surgery (CPT code 22869).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from December 18, 2020, 
through January 15, 2021. 
 
You asked the Plan to pay for the home health services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says there is no evidence that the home health 
agency in question was a Medicare certified provider. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
 
 
 
 Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the home health services provided from 
December 18, 2020, through January 15, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT 
code 22869). 
 
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says there are not enough scientific studies to show that inserting a device to open the 
narrowed space would be safe and effective for the enrollee. 
 
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 service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Vertilfex spacer remains experimental. More research is needed to show safety and 
efficacy. 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 service have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Vertiflex superion device placement surgery (CPT code 22869).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the progressive lens (V2781), polycarbonate or equal lens 
(V2784), polarization (V2762), and anti-reflective coating (V2750) provided on August 10, 2021. 
 
You asked the Plan to pay for the progressive lens, polycarbonate or equal lens, polarization, and anti-reflective 
coating. You say that you would like to be reimbursed. The Plan denied your request. The Plan says additional 
upgrade options are explicitly listed as not covered under the Vision Care benefit in the Evidence of Coverage. 
 
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 standard frames and lenses after cataract surgery. 
 
We looked at the file and the Plan's rules. Specifically, you received upgraded lenses which are not covered by 
the Plan. Based on this information, we decided that the Plan's rules for coverage of the progressive lens, 
polycarbonate or equal lens, polarization, and anti-reflective coating have not been met. Therefore, we decided 
that the Plan does not have to pay for the progressive lens (V2781), polycarbonate or equal lens (V2784), 
polarization (V2762), and anti-reflective coating (V2750) provided on August 10, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient initial hospital care (99221) provided on 
January 31, 2022. 
 
You asked the Plan to pay for the inpatient care. You say that the service was rendered in good faith. 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. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated.  
The enrollee ended Medicare Hospice benefits on January 28, 2022. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the inpatient initial 
hospital care (99221) provided on January 31, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a second Cochlear Auditory Implant (left ear). 
 
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says the documents did not show any functional deficiency in intelligibility with your current 
monaural that would be improved with a bilateral cochlear implant; therefore, your request has been denied. 
 
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 service. Our physician reviewer 
found the documentation does not support that you have bilateral moderate-to-profound sensorineural hearing 
impairment with limited benefit from appropriate hearing (or vibrotactile) aids. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a second Cochlear Auditory Implant (left ear).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cologuard testing. 
 
You asked the Plan to pre-approve the Cologuard testing. You say that  The Plan denied your request. The Plan 
says the rules for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that Cologuard testing is covered once every three 
years for beneficiaries who meet specific criteria.  
 
 
 
 We looked at the file and Medicare rules. The records show that the enrollee received Cologuard testing on 
November 19, 2021. This means that three years has not passed since the enrollee's last Cologuard test. Based 
on this information, we decided that Medicare rules for coverage of the Cologuard testing have not been met. 
Therefore, we decided that the Plan does not have to pre-approve Cologuard testing.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous implantation of neurostimulator electrode 
array, epidural (CPT code 63650). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says there is no documentation of appropriate psychological screening in this 
enrollee and the physician has verified that one has not been completed. 
 
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 service. Our physician reviewer 
found detailed documentation is not evident regarding this being a late or last resort. The documentation does 
not support having undergone a psychological clearance. There is no compelling rationale presented or 
extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. 
Therefore, the medical records provided do not meet the requirements listed in the LCD for Medicare coverage. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve percutaneous implantation of neurostimulator electrode array, epidural (CPT code 63650).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for genetic testing services provided to the enrollee on December 22, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that testing for the FANCC gene is not a Medicare benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that services are covered 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 pay for the services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that this testing is medically necessary and can be used to help determine treatment options. 
 
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 pay for 
genetic testing services provided to the enrollee on December 22, 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance transportation services (A0428, A0425) provided 
on January 17, 2022. 
 
You asked the Plan to pay for ambulance services. You say that this is a valid diagnosis code. The Plan denied 
your request. The Plan says diagnosis code F02.81 (dementia in other diseases classified elsewhere with 
behavioral disturbance) was reported as a principal diagnosis. This code is only eligible to be used as a 
secondary diagnosis code, with the underlying physiological condition coded first. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that manifestation diagnosis codes cannot be billed as the principal diagnosis.  
 
We find that code F02.81 is not supported as a principal diagnosis code. Specifically, F02.81 (dementia in other 
diseases classified elsewhere with behavioral disturbance) is a manifestation code with a code first note 
indicating that the underlying physiological condition should be coded as the principal. Based on this 
information, we decided that Medicare billing rules for this claim have not been met. Therefore, we decided 
that the Plan does not have to pay for ambulance transportation services (A0428, A0425) provided on January 
17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on February 17, 2022. 
 
You asked the Plan to pay for the testing services. You say that the testing was medically necessary for the 
management of the enrollee's advanced cancer. The Plan denied your request. The Plan says the testing is not a 
Medicare benefit. 
 
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. The file shows that the FoundationOne testing at issue includes the 
FANCC gene. Panels of tests that include the FANCC gene are statutorily excluded from service. 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 lab testing services provided on February 17, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the scanning computerized ophthalmic diagnostic imaging (92134) 
provided on March 8, 2022. 
 
You asked the Plan to pay for the ophthalmic diagnostic imaging. The Plan denied your request. The Plan says 
that you are responsible for a $35.53 copay for services from an in-network provider. 
 
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. 
 
We looked at the file and the Plan's rules. The contract clearly states that you are responsible for a $35 copay 
for Level 1 physician services to diagnose and treat diseases and conditions of the eye. It is reasonable that you 
believed the imaging provided during the office visit would be covered under the $35 copay. Based on this 
information, we decided that the Plan's rules for coverage of the ophthalmic diagnostic imaging have been met. 
Therefore, we decided that the Plan has to pay for the scanning computerized ophthalmic diagnostic imaging 
(92134) provided on March 8, 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ultrasound provided on August 30, 
2021. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that you did not see this provider and 
do not know who they are. The Plan denied your request. The Plan says the copayment was applied 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 $100 per 
day for Medicare-covered diagnostic radiology services.  
 
You have been asked to pay the allowed amount of $66.25 for the ultrasound rather than the standard $100 
copayment. The ultrasound falls within the Outpatient diagnostic tests and therapeutic services and supplies 
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 the ultrasound provided on 
August 30, 2021.