Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the diagnostic hearing exam provided on 
October 13, 2022. 
 
You asked the Plan to waive the copayment for the diagnostic hearing exam. You say that the copayment 
should be included with your office visit. 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 a $10 
copayment for in-network hearing services. 
 
You have been asked to pay a $10 copayment for the diagnostic hearing exam. This item/service falls within 
the in-network hearing 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 
the diagnostic hearing exam provided on October 13, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on October 19, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that the medical records provided support the 
need for the ambulance transport. The Plan denied your request. The Plan says ambulance transport, whether 
via ground or air, to or from an outpatient office or facility for a scheduled non-urgent visit is not a Medicare 
covered benefit. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when 
they meet certain origin and destination requirements. A doctors office is not a covered destination.  
 
The services you have asked the Plan to pay for are ambulance transport services to a doctors office. 
Therefore, we decided that the Plan does not have to pay for ambulance services provided on October 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the water circulating heat pad with pump (E0217) provided 
from June 17, 2022, to July 12, 2022, by an out-of-network provider. 
 
You asked the Plan to pay for the head pad. You say that the enrollee's plan has coverage for durable medical 
equipment. You also say that the charges are medically necessary. The Plan denied your request. The Plan says 
the water circulating heat pad with pump is not medically reasonable or necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a water circulating heat pad with pump will be 
denied as not reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the head pad have not been met. Therefore, we decided that the Plan does not have to pay for the 
water circulating heat pad with pump (E0217) provided from June 17, 2022, to July 12, 2022, by an out-of-
network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for definitive urine drug testing (UDT) for 15-21 drug classes 
(G0482) provided on September 7, 2022. 
 
You asked the Plan to pay for definitive UDT for 15-21 drug classes. You say that this testing was necessary 
and beneficial to the enrollee's healthcare. The Plan denied your request. The Plan says under Medicare rules, 
the number of definitive urine drug classes requested are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that definitive UDT is covered when it is reasonable and 
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 definitive UDT for 15-21 drug classes. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found that in this case, the 
diagnosis is medication management of long-term (current) drug therapy. The medical record sent by the 
provider shows presumptive screening test results which are partially inconsistent with prescription 
medications, or history and expected results.  Definitive confirmation testing was medically necessary for only 
1 drug class: Opiates. The review has determined that the enrollee did not meet criteria for UDT for 15-21 drug 
classes. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of definitive UDT for 15-21 drug classes have not been met. Therefore, we 
decided that the Plan does not have to pay for definitive urine drug testing (UDT) for 15-21 drug classes 
(G0482) provided on September 7, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on June 13, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you cannot 
afford to pay this bill. You also say that you were not aware this bill would not be covered. The Plan denied 
your request. The Plan says these services are not a covered benefit. 
 
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 June 13, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on June 13, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Rezum treatment. 
 
You asked the Plan to pre-approve Rezum treatment. The Plan denied your request. The Plan says this request 
is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that one treatment for LUTS/BPH treatment is covered 
once in patients with all of the indications listed in the Medicare rules section of this letter and no 
contraindications to the criteria listed in the Medicare rules section of this letter. 
 
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 Rezum treatment. Our reviewer says 
that the enrollee does not meet the criteria for coverage for the Rezum treatment. Our physician reviewer found 
the records do not show that the enrollee has failed three months of conventional medical therapy for BPH 
(e.g., alpha blocker, Phosphodiesterase-5 (PDE5) Inhibitor, finasteride/dutasteride) or that the enrollee is a poor 
candidate for other surgical interventions for BPH due to underlying disease (e.g., cardiac disease, pulmonary 
disease, etc.), or at high risk of bleeding. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Rezum treatment have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Rezum treatment.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary, rest home, or custodial care visit (code 99336) 
provided on October 24, 2022. 
 
You asked the Plan to pay for the domiciliary, rest home, or custodial care visit. You say that you are not 
responsible for getting an authorization. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or emergent, 
nor were they approved in advance. 
 
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 a domiciliary, rest home, or custodial care visit (code 99336) 
provided on October 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99226 billed for dates of service June 8, 
2022, to June 11, 2022. 
 
You asked the Plan to pay for the billed services. You say that the enrollee was in observation and turned 
inpatient. The Plan denied your request. The Plan says there is insufficient documentation to corroborate the 
services. 
 
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 99226 is not supported in the medical record. Specifically, the records do not include a 
physician order admitting the enrollee to observation status. Based on this information, we decided that 
Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure code 99226 billed for dates of service June 8, 2022, to June 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99223 billed for date of service March 25, 
2022. 
 
You asked the Plan to pay for the billed services. You say that medical records were provided. The Plan denied 
your request. The Plan says the billed code cannot be verified. 
 
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 99223 is initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission are of high severity.  
 
 
 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 billed services. Our reviewer found that 
the provided records document a comprehensive exam and medical decision making of high complexity. 
However, the records do not document a comprehensive history. Therefore, the billed code is not supported. 
 
We looked at this physicians review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure code 99223 billed for date of service March 25, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on November 25, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that the 
medical records provided support the need for the ambulance transport. The Plan denied your request. The Plan 
says these services are not a covered benefit. 
 
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 November 25, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on November 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (PCD) coded E0652 
with full leg (E0667) and trunk appliances (E0656). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that an E0652 PCD is covered when specific criteria 
are met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found there is no documentation of a trial and 
failure of at least four weeks of regular, daily, multiple-hour home usage of a standard pump after careful in-person fitting, training, and supervision by a technician who is skilled in and who regularly and successfully 
uses the appliance. The criteria for coverage are not met; therefore, the PCD and appliances are 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a pneumatic compression device (PCD) coded E0652 with full leg (E0667) and trunk 
appliances (E0656).
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 services are medically necessary as the enrollee 
is currently below baseline from a mobility perspective and was previously independent. The Plan denied your 
request. The Plan says the services are not reasonable and 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 enrollee does not require treatment by multiple therapies. 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 inpatient rehabilitation facility (IRF) admission and services.
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 has the best chance for a 
quicker recovery and more favorable outcome if admitted to LTACH. You say that the enrollee would have an 
individualized care plan and aggressive treatment to get them ready for the next level of care. The Plan denied 
your request. The Plan says the enrollee does not have clinical conditions that cannot be appropriately treated 
in the current hospital. 
 
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. All medically necessary care is being provided in the 
current acute care setting.  
 
 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 pre-approve intraoral imaging (D0210), a comprehensive oral 
evaluation (D0150), prophylaxis (D1110), and fluoride varnish (D1206). 
 
You asked the Plan to pre-approve the dental services. You say that you would like the Plan to pay for this. The 
Plan denied your request. The Plan says dental services from an out-of-network provider are not covered by 
your supplemental benefits. 
 
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. 
 
You are requesting dental services from an out-of-network provider. Though the Plan offers a dental benefit in 
excess of Medicare coverage, the requested items or services are not covered under this benefit when received 
from an out-of-network provider. Therefore, we decided that the Plan does not have to pre-approve intraoral 
imaging (D0210), a comprehensive oral evaluation (D0150), prophylaxis (D1110), and fluoride varnish 
(D1206).
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 enrollee has increased weakness in the lower 
extremities limiting their functional mobility to participate in daily activities. The Plan denied your request. 
The Plan says an IRF admission is not medically necessary, and the enrollee's needs can be met in another 
setting. 
 
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 enrollee is deconditioned without acute decline and has functioned at home. 
The enrollee does not have complex or intensive rehabilitation needs and has not received any home services. 
 
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: 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 highly motivated to participate, and 
they are able to tolerate three hours of therapy per day in an acute rehab setting. The Plan denied your request. 
The Plan says the enrollee's needs can be met in an alternate 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 clinical documentation shows that the enrollee may have complex functional 
impairments. There are no active medical comorbidities specified. The complexity of the enrollee's documented 
nursing, medical and rehabilitation needs would not be expected to require an acute hospital inpatient stay with 
an interdisciplinary approach to rehabilitation care. IRF criteria not met. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee arthroscopy (29880, 29981). 
 
You asked the Plan to pre-approve a knee arthroscopy. You say that the service is medically necessary. The 
Plan denied your request. The Plan says the service is not medically necessary. 
 
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 knee arthroscopy. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found detailed documentation is not evident regarding a trial and failure of recent, reasonable, 
comprehensive less invasive conservative care measures. Conservative care measures are the first-line 
treatments for meniscal pathology. There are limited large-scale, long-term references showing the safety and 
efficacy of the requested surgery in this clinical setting. There is no compelling rationale presented or 
extenuating circumstances noted to support the medical necessity of this request as an exception. 
 
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 knee arthroscopy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a knee arthroscopy (29880, 29981).