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

 
We decided that the Plan does not have to pay for the polymerase chain reaction (PCR) testing rendered on 
October 19, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were 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 pay for these services. Our reviewer says that the 
services were not medically necessary. Our physician reviewer found the enrollee had a suspected fungal nail 
infection. Testing for fungal nail infections (onychomycosis) is not standard of care as clinical assessment from physical findings usually show typical signs of a fungal infection and should be treated with antifungal 
medication (topical or oral). There was no explanation as to how testing would change treatment or overall 
outcome. Therefore, this request for PCR testing will be considered 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 pay for the polymerase chain reaction (PCR) testing rendered on October 19, 2021.
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 stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. The Plan states their 
needs can be met at a lower level of care, such as a skilled nursing facility (SNF) 
 
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 documentation does not support that the enrollee is stable for discharge from the 
acute care hospital and is ready for IRF care. It is not clear that the enrollee requires at least three (3) hours a 
day, five (5) days a week, or fifteen (15) hours over seven (7) consecutive days, of therapy services at this time.  
 It has not been demonstrated that there is a reasonable expectation that this enrollee will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vision protection plan (vision supply or service 
component of another vision code, V2797) purchased on November 30, 2021. 
 
You asked the Plan to pay for the protection plan. You say that you have a $250 allowance to use for eyewear, 
and you do not understand why this in-network service is denied. You say that you do not know how much will 
be charged to you for this service and would like any future payments to be cancelled. The Plan denied your 
request. The Plan says this service is not covered or payable under Medicare or the Plan's benefit. 
 
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 routine eye exams and eyeglasses (lenses and frames) or contact lenses. 
 
While the Plan offers a vision benefit in excess of Medicare coverage, the requested vision protection plan is 
not among those items/services covered under this benefit. Please note that this item is listed with a $25 cost on 
the submitted receipt, and it is possible that you paid this amount at the time of purchase. If you paid this 
amount to the provider either when the prescription was ordered or dispensed, you would not owe an additional 
amount for this service, but you are not entitled to reimbursement of this cost from the Plan. Therefore, we 
decided that the Plan does not have to pay for the vision protection plan (vision supply or service component of 
another vision code, V2797) purchased on November 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the single bitewing x-ray (D0270) or pay more for the 
periodic oral evaluation (D0120), four bitewing x-rays (D0274), prophylaxis (D1110), and crown (D2750) 
provided from August 31, 2021, to September 28, 2021, by an OON provider. 
 
You asked the Plan to pay for the single bitewing x-ray and to pay more for the periodic oral evaluation, four 
bitewing x-rays, prophylaxis, and crown. You say that the full amount for the exam, x-rays and cleaning should 
be paid. You also say that the x-ray and crown should be paid up to the $1,000.00 limit total. The Plan denied 
your request. The Plan says the frequency limit for bitewing x-rays has been exceeded. The Plan also says that 
your liability was applied correctly for these services per your plan 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, bitewing x-rays (codes D0270, D0272, 
D0273, D0274, and D0277) are limited to one procedure per plan year. The record shows that you received 
four bitewing x-rays (D0274) on August 31, 2021, which were covered by the Plan, and your bitewing x-rays 
benefit has been exhausted. You are also responsible for the difference between the billed amount and allowed 
amount for covered dental services that are received OON. Therefore, we decided that the Plan does not have 
to pay for the single bitewing x-ray (D0270) or pay more for the periodic oral evaluation (D0120), four 
bitewing x-rays (D0274), prophylaxis (D1110), and crown (D2750) provided from August 31, 2021, to 
September 28, 2021, by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electric scooter (E1230) provided on September 27, 
2021. 
 
You asked the Plan to pay for the electric scooter. You say that the service is medically necessary. The Plan 
denied your request. The Plan says sufficient documentation has not been received to review this 
equipment/service for medical necessity and appropriateness. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the electric scooter (E1230), provided 
on September 27, 2021. have been met. medical records. Therefore, we decided that the Plan does not have to 
pay for the electric scooter (E1230) provided on September 27, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on July 26, 2021. 
 
You asked the Plan to pay for the testing services. You say that there has been a misinterpretation of guidelines. 
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 code. The file shows that Guardant360 testing was provided. We looked at the file and the rules. If an independent 
lab bills for services, the place where the sample was taken is reported as the place of service. The claim lists a 
place of service as an independent laboratory. The records do not show that the specimen was obtained at an 
independent laboratory. Based on this information, we decided that Medicare rules for coverage of the testing 
services have not been met. Therefore, we decided that the Plan does not have to pay for the lab testing services 
provided on July 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter. 
 
You asked the Plan to pre-approve a power scooter. You say that you cannot walk and need a scooter. The Plan 
denied your request. The Plan says that records received do not show that you cannot use a cane, walker, or 
manual wheelchair to complete your MRADLs. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 power scooter. Our reviewer says that 
a power scooter is not medically reasonable and necessary. There is documentation that you have a personal 
mobility deficit, but records do not clarify that the deficit impairs participation in mobility related activities of 
daily living such as toileting, feeding, grooming and bathing in customary locations within the home. There is 
no documentation that your mobility deficit cannot be helped by the use of a walker, cane or manual wheelchair. There is no documentation that the patient can safely operate a power mobility device. Our 
physician reviewer found that your condition does not meet Medicare criteria for a power scooter. 
 
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 power scooter have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power scooter.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on August 11, 
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 an appropriate modifier was not used. 
 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 70450 
is a column II code to column I code 70496. 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 imaging services provided to the enrollee on August 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the imaging services provided on September 22, 2021. 
 
You asked the Plan to pay for the services provided. You say that modifier 26 is valid for the procedure code. 
The Plan denied your request. The Plan says the claim denied correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 The file shows that the enrollee received a chest x-ray and computed tomography (CT) scan. The records show 
that these services were previously billed and paid for by the Plan. Claims or claim lines that have been 
determined to be exact duplicates of another claim are denied. Based on this information, we decided that 
Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan 
does not have to pay for the imaging services provided on September 22, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on October 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 the provider did not bill as required by Medicare coding regulations. 
 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 70450 
is a column II code to column I code 70496. 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 imaging services provided to the enrollee on October 22, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services provided to the enrollee from June 9, 2020, 
to June 10, 2020. 
 
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 the DRG was updated. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 689 (KIDNEY AND URINARY TRACT 
INFECTIONS WITH MCC). The plan updated to DRG 690 (KIDNEY AND URINARY TRACT 
INFECTIONS WITHOUT MCC). 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 services at issue in this were supported by the medical records. Our physician 
reviewer found the enrollee is a 93-year-old woman with a history of heart disease, stroke, hypertension, 
recurrent UTIs, and dementia, who was admitted to the hospital on 6/9/2020 with accelerated hypertension, 
altered mental status, acute cystitis without hematuria, and elevated troponin. The documentation supports 
DRG 689. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do substantiate the DRG as billed. Therefore, we decided that the Plan has to pay for inpatient 
hospital services provided to the enrollee from June 9, 2020, to June 10, 2020.  
 
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 pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF 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 based on the medical records provided the complexity of the patient's nursing, 
medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care. The patients medical conditions are stable on outpatient medications with no 
issues that require a physicians evaluation three (3) or more times per week. The patient does require physical therapy and occupational therapy services but based on the medical records provided the patient does not 
require an intensive inpatient rehabilitation therapy program. There is concern that the patient will not be able 
to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient 
rehabilitation facility due to their significantly impaired endurance. Care at the skilled nursing facility level 
appears to be appropriate in this case. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on July 8, 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 there is evidence of misrepresented services. 
 
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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the provided records did not clearly provide an explanation as to why the treating physician needed this 
genetic information in this case or why it would change treatment. Genetic testing like this has not been proven 
to lead to improved overall outcome to support its general use. Therefore, without sufficient support made, this 
request for genetic testing will be considered not medically necessary at this time.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for laboratory services provided to the enrollee on July 8, 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 your current medical condition does not require intensive physician or nursing 
supervision in an IRF. You may benefit from additional physical and occupational therapy, but the 
documentation does not reveal that this therapy must be only on an intensive level 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete 
series of intraoral x-rays (D0210) provided on November 8, 2021. 
 
You asked the Plan to pay for the comprehensive oral evaluation and complete series of intraoral x-rays. You 
say that this was a new dentist who had to do an oral exam and x-rays. The Plan denied your request. The Plan 
says these services exceed the maximums allowed per period. 
 
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. 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, comprehensive oral evaluation 
(D0150) and complete series of intraoral x-rays (D0210) are each limited to one procedure every three plan 
years. The record shows that you received a comprehensive oral evaluation (D0150) on March 1, 2019, and 
you received a complete series of intraoral x-rays (D0210) on March 2, 2020 and your comprehensive oral 
evaluation (D0150) and complete series of intraoral x-rays (D0210) benefits have been exhausted. Therefore, 
we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete 
series of intraoral x-rays (D0210) provided on November 8, 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 you have no one to take care of you and you need 
IRF care. The Plan denied your request. The Plan says criteria for admission to the IRF setting have not been 
met. Your ongoing skilled therapy and nursing needs can be provided 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 that based on the documentation provided, you are not shown to require fifteen 
hours per week of rehabilitative services and regular physician evaluation. 
 
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.